Basic Information
| Provider Information | |||||||||
| NPI: | 1871588384 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEES | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 74751 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441940834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409972262 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2420 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | ASHTABULA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440044954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409972262 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 11/24/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | COA.00528-NA | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0775997 | 05 | OH | MEDICAID |